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Draft National Prevention Strategy: Samueli, IHPC, AANP, ACA, NCH,SIO, Pino, Maclean, Weeks Respond PDF Print E-mail
Written by John Weeks   
Friday, 28 January 2011

Draft National Prevention (and Health Promotion) Strategy: Samueli, IHPC, AANP, NCH, ACA, SIO, Pino, Maclean, Weeks Respond

Summary: In the short, holiday-filled time frame for responding to the National Prevention, Health Promotion and Public Health Council's draft National Prevention (and Health Promotion) Strategy, some in the integrative practice community did. All but one of the following was then sent to the Integrator. I gathered the other from the web. Included is a note from the Society for Integrative Oncology followed by submissions from the Samueli Institute, Integrated Healthcare Policy Consortium, American Chiropractic Association, American Association of Naturopathic Physicians, National Center for Homeopathy, consumer leader Charles Maclean, PhD, acupuncturist Karah Pino, LAc, MAcOM, and yours truly. I conclude with a brief list of common themes, and two references to the scholarly work of Theodor Geisel.

Send your comments to
for inclusion in a future Integrator.

The value of these integrative practice organizations sharing their perspectives publicly is that we can begin to see where common themes emerge and lines of continuity exist. Thanks to each of these organizations and individuals for sharing. Here - as noted in my summary at the bottom of this posting - are the common themes I have culled.

  • Don't publish until you have input from the Advisory Group. Appoint it!
  • Changes the title. National prevention Strategy will put people to sleep. Got a problem with engagement? This title guarantees the public will stay disengaged.
  • Present definitions and approaches are too limited for a transformational outcome.
  • Explore new types of practices and practitioners.
  • Use emerging community and self-care resources.
  • Engage integrative practice research that has health and wellness outcomes.
  • We need more research before we can declare a transformational national strategy so proceed with that full in mind.

What might you add? Thanks to the Samueli Institute, Integrated Healthcare Policy Consortium, American Chiropractic Association, American Association of Naturopathic Physicians, National Center for Homeopathy, consumer leader Charles Maclean, PhD, and acupuncturist Karah Pino, LAc, MAcOM for allowing this look into what connects us. I also include my own submission, from which I developed this previously published column: Positive Side-Effects: Evidence of Prevention & Health Promotion via Integrative Clinical Practices from Ornish, Cherkin-Sherman, Seely-Herman & Gaby.

_________________________________


Image
Urged action from members
1.  Society for Integrative Oncology urges members to participate


A sign of the potential value of this Strategy in advancing integrative principles in practice was the following note, published by the Society for Integrative Oncology to its members:
Dear Colleagues and Friends,
A 'National Prevention and Health Promotion Strategy' is being developed as part of the Affordable Care Act. The goal is to shift the nation from a focus on sickness and disease to one based on wellness and prevention. The National Prevention Council is inviting comments on the draft of the National Prevention Strategy. This represents an excellent opportunity for our voices to be heard and our ideals of integrative cancer care to be incorporated in the final National Prevention Strategy, which is to be released later this year.

We urge everyone who feels strongly about an integrative approach to health and wellness to take this opportunity to review the draft Strategy and make your comments at http://www.hhs.gov/news/reports/nphps.html. The comment period ends this Thursday, January 13, 2011.

Thank you for your assistance and continued support,

Executive Board Committee
Society for Integrative Oncology
Comment:  It was good to see this level of activism by SIO. A similar "push" was sent out by the Center for Integrative Medicine at Wake Forest University in their January 2011 newsletter. I also had a few quick responses to the Integrator Alert from readers, including my sister Pam Weeks, MA, who wished the Alert had included a draft response and was connected to a CapWiz type function to facilitate submissions. Unfortunately, that much organizing is beyond the Integrator's marginal bandwidth. Hopefully in time we will have the potential for a more robust and organized response to such issues.

Image
Urged member organizations to participate
2. Integrated Healthcare Policy Consortium response


Janet Kahn, PhD, executive director of the multidisciplinary Integrated Healthcare Policy Consortium, sent a note to a set of integrative health policy leaders that IHPC helped convene in late September 2010. The note began by urging IHPC's member organizations to respond. It then included these comments as submitted by IHPC:

1) Overall the draft policy is sound and well-directed, but it is lacking in a few areas, as stipulated below.

2) The White House should immediately appoint the Advisory Council, with the composition specified in Public Law 111-148, the Patient Protection and Affordable Care Act of 2010, so that the diverse perspectives stipulated, including the perspective of integrated health care can be part of determining the strategy and not relegated to simply helping to implement something they were not able to frame.

3) As described by the Integrated Healthcare Policy Consortium, Integrated Health Care describes a coordinated system in which healthcare professionals across the conventional, complementary and alternative spectrum are educated about one another's work and collaborate with one another, and with their patients, to achieve optimal well-being for the patient. Integrated healthcare policy describes an approach to policymaking that puts the health of the nation's population as a key consideration in all domestic policy initiatives and decisions.

   
     
 IHPC encourage more comparative
effectiveness research (CER) and
"the inclusion in CER studies of at
least one CAM/CIM ... arm in every
CER study" where there might
be a benefit.
 
4) This draft strategy does not place enough explicit emphasis on primary prevention. In comments made by President Obama over the course of developing the Patient Protection and Affordable Care Act, and continuing to today, there has sometimes been confusion about what constitutes prevention, or preventive action. Beware of placing too much emphasis on diagnostic tests alone, without strong focus on what patients and providers are to do once they have the diagnostic information. For example, having a colonoscopy is not exactly a preventive behavior. It is a diagnostic test whose chief goal is early disease detection. It only becomes an aspect of prevention when it leads to healthier dietary and other related behaviors if vulnerability is detected.  The behavioral changes are the actual prevention.  This partnership of information and action should be stressed throughout the strategy.

5) The emphasis on evidence-based action/priorities/etc. assumes that we have the information we need for good decision-making, yet as Tunis, Stryer and Clancy (Practical Clinical Trials: Increasing the Value of Clinical Research for Decision Making in Clinical and Health Policy; JAMA September 24, 2003, Vol. 290, No. 12, pp.1624-1632) have pointed out, and as the current enthusiasm for Comparative Effectiveness Research reflects, we do not yet have the information we need for good decision-making. Thus, we feel that the National Prevention Strategy must take this into account and support the use of CER funds by PCORI, to address some of the questions that need to be answered to develop a sound prevention strategy. In particular, we encourage the inclusion in CER studies of at least one CAM/CIM (Complementary, alternative or integrative medicine) arm in every CER study for which there is reasonable evidence that a CAM/CIM treatment might be of benefit. It must be recognized that one of the merits of most CAM approaches is their relative lack of negative side effects. CER studies should be directed to include CAM/CIM arms and to be comprehensive in their measurement of cost, such that this includes health care costs resulting from treatment complications, as well as costs directed at treatment.

   
"Systems such as acupuncture and Oriental
medicine, Ayurvedic medicine, chiropractic,
 homeopathic and naturopathic medicine,
and Indigenous medicines see people in their
wholeness and in their web of relationships
to the family/clan/environment ..."
 
  
6) It is vital to support people in becoming empowered in relation to their own health and well-being, yet mainstream American medicine does not yet do this well. Patient empowerment has been an aspect of most complementary and alternative systems of medicine for ages.  Systems such as acupuncture and Oriental medicine, Ayurvedic medicine, chiropractic, homeopathic and naturopathic medicine, and Indigenous medicines see people in their wholeness and in their web of relationships to the family/clan/environment.  From this basis, it is possible that practitioners of these approaches are particularly effective in supporting patients to take good care of themselves, to embrace their share of responsibility for their health and well-being.  Or perhaps these practitioners are not more effective than allopathic providers in helping their patients adopt healthy behaviors. The key point is that we need to learn how to best support people to change behaviors. It has been a challenge to social scientists for decades - how do we get teenagers to either abstain from having sex or use contraception? How do we get people to not smoke a first cigarette, or to stop smoking once begun?  We have some answers based upon our relative success with smoking cessation, which points to the potency of aligning multiple layers of policy and incentive (economic, social, legal, etc.).  And this strategy speaks to the whole and complex approach. But the question of how a provider can be most effective remains unanswered and should be deeply investigated.

7) The Integrated Healthcare Policy Consortium is willing to help this effort in any way possible. We have providers across the conventional, behavioral, complementary and alternative medicine spectrum, as well as medical sociologists and economists keenly engaged in these issues and available to support your efforts.

Janet R. Kahn, PhD
Executive Director
Integrated Healthcare Policy Consortium
www.ihpc.info

Image
Responded to both opportunities for input
3. Samueli Institute's Wayne Jonas, MD on the draft plan, and the earlier framework


The Samueli Institute was one of the only entities involved in the integrative practice field to respond to both comment periods: the framework and then the strategy. For good reason: Samueli Institute was instrumental in formulating the concept of the Council. In a note to the Integrator, Wayne Jonas, MD, Samueli Institute's CEO noted an overall sense that the draft strategy's "focus still seems to on preventing death rather than improving health." He also noted that "delay(ing) appointing the Advisory Group means there won't be much to advise them on if the 'Strategy' is already in place."
I attach the Institute's submission on the strategy's guidelines, published here in the Integrator, below this more recent response to the draft Strategy.
1. The Council is tasked w/ processes for continual public input yet one of the best sources would be the Advisory Group which, to my knowledge, has not been appointed (despite the timeline that has passed as established during the July meeting), so believe that ought to be a priority.

   
"The title has been shortened to
"National Prevention Strategy" which
shortchanges the breadth of the
Council's title and mandate. An
appropriate title should be sought."
 
   
2. Administratively, the title of the Strategy has been shortened to "National Prevention Strategy" which shortchanges the breadth of the Council's title and mandate, so an appropriate title should be sought.

3. The Council's purposes include "(4) consider and propose evidence-based models, policies, and innovative approaches for the promotion of transformative models of prevention, integrative health, and public health on individual and community levels across the United States."  Seems the Surgeon General and the Council should implement a more aggressive than is apparent approach to identifying, researching and evaluating approaches--a dedicated effort to identify and provide visibility to approaches effective and not widely implemented.

4. We have discussed the power of access to funds, so encouraging a more formal alignment and influence of the Council over the section 4002 Fund would be appropriate (probably through formal recommendations to Congress and HHS leadership).  Access to funds is influence.

5. The approach of the draft strategic direction is narrow to prevention and seems to be oriented so that "all Federal agencies are included and have a role" more so than covering the wellness spectrum--although it does include some aspects of TFF.  So a focus on Total Force Fitness as a more inclusive approach to wellness would be beneficial.  And, to highlight the advances made by DoD in view of its challenges of sustaining a healthy force in the face of two prolonged conflicts.

   
  
 "The draft goals are much too narrow
and should be enhanced to be more
integrative, more wellness oriented,
more evidence-based, more
transformative
models ..."

6. The draft goals are two: create community environments that make healthy choice the easy and affordable choice; and implement effective preventive practices.  Seems they are much too narrow and should be enhanced to be more integrative, more wellness oriented, more evidence-based, more transformative models, more recognition of the power of positive or negative individual behaviors and how little is known/effective in that regard.
Comment: This response (and that below) from the Samueli Institute show both how close the Institute has been to the new Council and the value of having a professional lobbyist to help with drafting such responses. The short story: the draft strategy simply misses the mark. I agree that much was lost in shortening the name of the Council and the Strategy to the focus on "Prevention." Doing so showed that no one at the wheel is enough in touch with the public to realize that this message in this title is more of the same. Bring in Madison Avenue, maybe.

The Samueli Institute response to the draft framework is below:

1.    The primary goal of increasing gains in life expectancy is too limited and fails to address the mission of improved function, productivity and quality of life. 
2.    Modify the Draft Vision to read "Working together to improve the health and quality of life for individuals, families, and communities by moving the nation from a focus on sickness and disease to one based on integrative care, health promotion, wellness and prevention."

3.    Add to (SD4): (R) Go beyond prevention and disease screening to active health promotion and integrative health care.

4.    The ACA law provides that the National Prevention and Health Promotion Strategy "set specific goals and objectives for improving the health of the United States..."  The strategic directions and recommendations outlined in this draft use passive action verbs (such as "plan and develop," "foster," and "use") which fall short of the guidance of specific goals and objectives.  To "shift the nation from a focus on sickness and disease to one based on wellness and prevention" will require more aggressive action and dramatic new approaches not evident in the draft strategy.

5. Further, the law specifies that the strategy "make recommendations to improve Federal efforts...consistent with available standards and evidence."  However, there is little evidence of how specifically those standards and evidence are incorporated.

6. The strategy talks to tracking the progress to ensure accountability but does not talk directly to how and whether the individual recommendations will be evaluated and against what standards will they be judged to ensure enhanced wellness and reduced costs.   It would be powerful for the strategy to outline an ongoing evaluation and recommendation/resource reallocation process to ensure the most effective approaches are sustained and those failing to improve wellness and prevention are eliminated or recrafted.

   
 "The strategy speaks little about incentives
for individuals, communities, and public and
private sector institutions to deliver and
consume the health and wellness practices
and products that will positively impact
wellness and reduce costs."

   
7. The strategy speaks little about incentives for individuals, communities, and public and private sector institutions to deliver and consume the health and wellness practices and products that will positively impact wellness and reduce costs.  The key component for widespread acceptance and uptake of any prevention and promotion recommendations will be the development of and individual and community use of new, effective incentives that take the Nation beyond current practices which have experienced uneven results.

8. The strategy could be strengthened by including the availability of advanced information tracking and feedback systems (applied wellness toolkits) so that individuals and communities are able in real-time to understand the progress toward wellness and to realign efforts that are not achieving that goal.

9.  The process of strategy development would be improved if the Advisory Group required by law were appointed and successfully integrated into policy development.

10. The wide spread use of complementary and integrative health care is not addressed yet is specifically incorporated into the law.  This should be addressed as follows:
Add: (SD12) Integrative Health Care

(R) Identify evidence-based integrative practices such as mind-body, acupuncture, massage, and establish a process to make them available.

(R) Promote alternatives to drug approaches for prevention and treatment that have good evidence for effectiveness.

(R) Establish demonstration models into community health care with integrative models.

(R) Develop a whole systems model for evaluating and comparing impact of integrative models of health practices for communities.

Image4.  American Chiropractic Association


John Falardeau, vice president for government relations for the American Chiropractic Association, forwarded these comments filed by the ACA.
The American Chiropractic Association (ACA) is a professional society composed of doctors of chiropractic whose goal is to promote the highest standards of ethics and essential patient care, contributing to the health and well being of millions of patients. The ACA is the largest association in America representing the chiropractic profession. Included below are ACA's comments regarding the National Prevention Council's Draft of their Vision, Goals, Strategic Directions, and Recommendations.

What are your suggestions on the Draft Vision, Goals, Strategic Directions, or Recommendations?
 
The National Prevention Strategy has indicated it will base its recommendations and action items on "evidence-based prevention policy and program initiatives."  The ACA believes it is important to indicate exactly how the National Prevention Strategy defines "evidence based."   The ACA supports the definition of evidence based medicine as follows: "Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients' predicaments, rights, and preferences in making clinical decisions about their care. By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. External clinical evidence both invalidates previously accepted diagnostic tests and treatments and replaces them with new ones that are more powerful, more accurate, more efficacious, and safer."(Sackett, D.L. et al. (1996), Evidence based medicine: What it is and What it isn't . BMJ 312 (7023), 13 January, 71-72.)  The ACA requests that the Council clearly explain their interpretation of evidence based as varying definitions and interpretations could greatly impact the work of the Council. 

   
    
"The ACA requests that the Council
clearly explain their interpretation of
evidence based as varying definitions
and interpretations could greatly
impact the work of the Council."
  

With regard to eliminating health disparities, the ACA believes that many of our Federal healthcare programs which focus on specific populations, like the Indian Health Services (IHS), need to be revaluated.  Currently, there are Alaskan Native American Indian doctors of chiropractic who have tremendous cultural knowledge, but are unable to have access through the IHS to provide services for tribes and have those services reimbursed.  To reduce healthcare costs, we must use all available resources.  Under the current IHS system, those who possess prevention focused, low cost, drug free approaches to common health ailments and direct cultural knowledge are being excluded from the system at the detriment of a whole population.  This and other program policies need to be reexamined for the benefit of those populations.

The ACA supports the efforts of the Council to expand interoperable health information technology. In an effort to encourage use of health information technology by doctors of chiropractic, the ACA has partnered with one of the nation's top providers of chiropractic software, Future Health, Inc., to make EHR use and practice management easier and affordable for doctors of chiropractic.  We appreciate that the Council is also dedicated to the goal of increasing health information technology use to improve healthcare quality and increase the use of preventive health measures. 

Since its inception, chiropractic has been based on an active care model that emphasizes health promotion and wellness.  As such, we support and appreciate the efforts of the National Prevention Council to increase the health of the American public.  The Council's focus on health, wellness and prevention mirrors many of the fundamentals of chiropractic practice.  For example, in the chiropractic profession, the commitment of the doctor of chiropractic to wellness emphasizes collaboration with patients on the development of a lifelong path for health promotion and disease prevention.  Health promotion and wellness are based on a patient-centered paradigm. Incorporating knowledge, skills and attitudes acquired through professional training, the doctor of chiropractic works with patients as partners in a number of domains, including:

  • Evaluation/Assessment of Patients (risk factors, health needs)
  • Information/Education of Patients (awareness)
  • Intervention/Monitoring (including counseling)
  • Integration with other Community Resources

   
 
"Since its inception, chiropractic has been
based on an active care model that emphasizes
health promotion and wellness."

 
   
As you can see, the model of care employed by doctors of chiropractic is in close alignment with many of the goals of the Council.  As such, overall, we believe that the Council's goals are reasonable and appropriate.  Working towards greater individual health with more healthy communities, focusing on prevention and empowering individuals to make healthy choices are all sounds goals.  However, we believe that one noticeable aspect may be missing from the Council's draft. 

Throughout the draft, the need for different types of education is noted.  According to the Council, efforts should be made to educate individuals regarding healthy eating and how to become more active.  While it is clear that these educational efforts must be made, we believe that individuals must also be educated on the availability of less invasive and less costly healthcare interventions.  The Council notes that chronic diseases and conditions account for at least 7 of every 10 deaths in the United States and for more than 75% percent of medical care expenditures.  Clearly, our healthcare system's approach to dealing with disease is not functional and is unsustainable.  We must examine the interventions that are used for the most common chronic conditions and begin to explore other options available to patients.  To achieve the goals of the council, we believe that an effort must be noted in the Council's recommendations to educate individuals regarding the range of healthcare options that are available to them, rather than to simply continue to use traditional medical and surgical interventions that are often more costly and may not address the root causes of disease.  

   
    
 

"An effort must be noted to educate individuals
regarding the range of healthcare options that
are available to them, rather than to simply
continue to use traditional medical
and surgical interventions."

What evidence-based actions should the federal government take to address the Draft Recommendations?

The federal government is in a position whereby it could begin to implement rules and regulations consistent with the goals of the Council.  However, this sort of top down implementation seems contrary to the goal of the Council to empower individuals.  Additionally, it has been shown in the private sector that wellness programs that provide incentives rather than penalties can often be highly successful.  As such, the federal government may consider providing incentives to states and organizations that make efforts and achieve goals consistent with those of the Council.  Additionally, we believe that it is essential for the President to appoint the Advisory Group to the Council, as mandated by the Patient Protection and Affordable Care Act. The guidance and expertise that an Advisory Group that includes integrative health practitioners will be invaluable to the Council. 

   
"The guidance and expertise that an
Advisory Group that includes integrative
health practitioners will be invaluable
to the Council."
  

    
The federal government also has the responsibility to ensure that the Patient Protection and Affordable Care Act (PPACA) is properly implemented.  PPACA has already underscored the great importance of provider choice in Section 2706 which states, "A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider's license or certification under applicable State law." The ACA recommends that the Council and federal government communicate to patients their right to provider choice and explain the non-discrimination provision to patients so they understand that any healthcare provider acting within their scope of practice can provide preventive services.
 
What evidence-based actions should partners (national, state, Tribal, local, and Territorial governments, non-profit, and private) take to address the Draft Recommendations?

The healthcare provider community is going to be instrumental in the achievement of the Council's goals.  However, the Council makes little mention of the role that healthcare providers can play in these efforts.  As such, we believe that healthcare provider organizations should be actively involved in communicating the goals and messages of the council. The council must also remain open to receiving input from healthcare provider organizations that are closer to the healthcare provider community and are more familiar with how best to engage providers in an effort to achieve the Council's goals, when appropriate. 

What measures should be used to monitor progress on implementation of the National Prevention Strategy's Vision, Goals, and Recommendations?

Attempts should be made to quantify efforts to:

  • Increase Physical Activity or Exercise
  • Provide Nutritional Guidance
  • Encourage Weight Control
  • Encourage Smoking Cessation
  • Reduce Alcohol Consumption
  • Promote Stress Management
  • Promote Breast Feeding
  • Avoid or minimize exposure to pollution

When possible, public surveys should be conducted to determine the impacts of these efforts.

Image5. American Association of Naturopathic Physicians (AANP)

I was able to pluck this response from the AANP website shortly before posting this.


What are your suggestions on the Draft Vision, Goals, Strategic Directions, or Recommendations?

   
    
 "This Draft Strategy ignores the importance
and impact of integrative health care and
waylays the concept of health promotion,
instead relying on conventional definitions
of health care prevention as the
underpinning of the strategy."
 
Incorporated into the mandated strategy of the National Prevention, Health Promotion, and Public Health Council is language calling for recommendations on improving "federal prevention, health promotion, public health, and integrative health care practices..."  Abbreviating the Council name and strategy to read "National Prevention" Strategy and Council dramatically restricts the scope of this work and the ability to positively impact the health status of the Nation. Utilization of integrative health care practitioners is heavily emphasized in Title V of the Act, which is focused on workforce development. Yet, this Draft Strategy ignores the importance and impact of integrative health care and waylays the concept of health promotion, instead relying on conventional definitions of health care prevention as the underpinning of the strategy.  

While conventional medicine's focus on treatment of disease has produced many benefits-especially in acute and life-threatening conditions - its effectiveness for the promotion of health and the treatment of chronic disease is limited.  The report is quite comprehensive in its assessment of the range of issues impacting health, including environmental and lifestyle factors.  However, it fails to address the range of health promotion, wellness and true prevention practices utilized by practitioners other than medical and osteopathic doctors.  We know patients are best served when they have access to a team of health care professionals who work together to ensure overall health and wellness. Patients rely on the many and varied health services provided by naturopathic physicians, advance practice nurses, physical therapists, and many others, all of whom provide quality care and services in states across the country that have a direct impact on health status and the prevention of chronic disease.  

The Advisory Group membership, yet to be named, needs to reflect the breadth of practitioners and institutions who currently serve and educate patients on how to maximize their health status, and prevent chronic disease, including naturopathic physicians.

What evidence-based actions should the federal government take to address the Draft Recommendations?


The ability to address those health care conditions, such as diabetes, that disproportionately affect under-served and at-risk populations requires the federal government to utilize the expertise of a larger milieu of health care providers, including naturopathic physicians.  Expansion of eligibility for all Federal Loan Repayment Programs to naturopathic physicians and other providers who are trained to prevent and treat chronic disease is required in any effort to eliminate health disparities. 

   
"Redefining our cultural standard of health
requires integration of wellness and
prevention strategies that address the
nutritional, psychological, physical, social,
spiritual, and financial needs of
the individual person."
 
   
Second, redefining our cultural standard of health requires integration of wellness and prevention strategies that address the nutritional, psychological, physical, social, spiritual, and financial needs of the individual person. Stress-related illness accounts for 25-40% of all illness, yet proven strategies for reducing stress including yoga, meditation, and nutritional supplementation are not valued in the current health care system. As a result, we reward practitioners and payors for the most invasive and most expensive treatment strategies.

The naturopathic medical therapeutic order, articulated below, is the basic approach taken by naturopathic physicians to guide patients to wellness, beginning with the least force and moving to more invasive means as necessary. It stands as an example of how the government can redefine our current reliance on diagnostics and integrate effective prevention strategies into a national prevention and health promotion strategy.

  1. Re-establish the basis for health, removing obstacles to cure by establishing a healthy regimen.
  2. Stimulate the body's inherent ability to maintain and restore optimal health using various modalities and systems of health-botanicals, homeopathy, nutrition, hydrotherapy, touch, counseling, and Chinese medicine.
  3.    
         
    "The naturopathic medical therapeutic order
    is the basic approach taken by naturopathic
    physicians to guide patients to wellness,
     beginning with the least force and moving
    to more invasive means as necessary."

    Support weakened systems using modalities to strengthen the immune system, decrease inflammation, optimize metabolic functioning, balance regulatory systems, enhance regeneration, and increase vitality.
  4. Correct structural integrity, correcting physical imbalances by use of exercise, manipulation, massage, and targeted nutrition.
  5. Prescribe specific natural substances for pathology including vitamins, minerals, herbs, diet, breathing techniques, and hydrotherapies to target specific disease progression.
  6. Prescribe pharmaceutical intervention to halt and palliate disease process.
  7. Recommend surgery, suppressive measures, radiation, and chemotherapy.
And third, the government needs to define "Integrative Health Care Practitioner," as referenced in the Act.  The AANP proposes the following definition:
An Integrative Health Care Practitioner, acting within the scope of that provider's license or certification under applicable State law, addresses the underlying causal factors associated with chronic disease; improves individual health and increase individual capacity to engage in activities of daily living through lifestyle change, including strategies relating to diet, exercise, smoking cessation, and stress reduction; and provides patient-centered care that
(A) addresses personal health needs;
(B) uses a multidimensional approach to encourage patients to improve their own wellness through lifestyle changes and the use of scientifically based therapies and outcomes based treatments that facilitate the inherent ability of the human body to maintain and restore optimal health, and
(C) utilize clearly defined standards to determine when the implementation of wellness and health promotion activities will be useful for each patient based on the diet, exercise habits, individual health history, and family health history of the patient

What evidence-based actions should partners (national, state, Tribal, local, and Territorial governments, non-profit, and private) take to address the Draft Recommendations?

The Draft Report recommendation to "cross-train professionals in multiple sectors in the delivery of prevention and health promotion strategies" enables all stakeholders to participate in a reinvention of how primary care is delivered.  This cross-training needs to incorporate alternative systems of care, including naturopathic medicine, a system of care rooted in the belief that patient-centered care facilitates the inherent ability of the human body to maintain and restore optimal health.  Utilizing education and training, provided by institutions accredited by Agencies of the U.S. Department of Education, that incorporates nutritional, psychological, physical, social, spiritual and financial needs of the individual person is essential to this initiative.

What measures should be used to monitor progress on implementation of the National Prevention Strategy's Vision, Goals, and Recommendations?

   
"Funding research for systems of care
will enable the development of a new
model of primary care; one that
 incorporates the best of what both
conventional and complementary and
alternative medicine can offer and
focuses on prevention, health promotion,
and treatment of the whole person."
 
   
The Draft Report calls for implementation of proven strategies and ongoing research where evidence is either insufficient, where more effective strategies are needed, or where cost-effectiveness studies are lacking.  This affords an opportunity to focus on numerous high-quality, cost-effective medical practice patterns of highly skilled physicians and practitioners, including naturopathic physicians, for the purpose of conducting quality, outcomes-based research.  Funding research for systems of care will enable the development of a new model of primary care; one that incorporates the best of what both conventional and complementary and alternative medicine can offer and focuses on prevention, health promotion, and treatment of the whole person. Utilization of health information technology and electronic medical records in a practice-based research network (PBRN) will enable measurement of effectiveness of health promotion and care to reduce the societal cost and economic burden of chronic diseases, including type 2 diabetes.
Image
Charles Maclean, PhD
6.  National Center for Homeopathy


The president of the National Center for Homeopathy,
Nancy Gahles, DC, CCH, RSHom(NA), forwarded this submission.
The draft framework on the National Prevention Strategy does not include input from relevant stakeholders from the integrated  healthcare community. The Patient Protection and Affordable Care Act (PPACA), SEC. 4001(f),(1) provides for an Advisory Group on Prevention, Health Promotion, and Integrative and Public Health.

The draft strategy as put forth includes the known aspects of the prevailing Public health approach but does not include the Integrative approach.


The National Center for Homeopathy advocates for the intent of the law to be carried out in the final document insofar as the provisions call for:
SEC. 4001.NATIONAL PREVENTION, HEALTH PROMOTION AND PUBLIC HEALTH COUNCIL(d)(2) after obtaining input from relevant stakeholders, develop a national prevention, INTEGRATIVE HEALTHCARE strategy that incorporates the most effective and achievable means of improving the health status of Americans and reducing the incidence of preventable illness and disability in the United States. (d)(4) consider and propose evidence-based models, policies, and innovative approaches for the promotion of transformative models of prevention, INTEGRATIVE HEALTH, and public health on individual and community levels across the United States (5) establish processes for continual public input from State, regional, and local leadership communities and other relevant stakeholders...(f)(A) The Advisory Group (B) REPRESENTATION-In appointing members under sub-paragraph (A), the President shall ensure that the Advisory Group INCLUDES A DIVERSE GROUP of licensed health professionals INCLUDING INTEGRATIVE HEALTH PRACTITIONERS...
   
"The draft strategy as put forth
includes the known aspects of the
prevailing Public health approach
but does not include the
Integrative approach."

 

 
The law is clear. Licensed CAM providers and integrative healthcare practitioners are mentioned in 7 places in PPACA, SEC.2706. Non-discrimination in health care; SEC.3502. Establishing community health teams to support the patient-centered medical home; SEC.4001. The national prevention,health promotion and public health council; SEC.4206. Demonstration project concerning individualized wellness plan;national hhealthcare workforce commission; SEC.6301. Patient-centered outcomes research;SEC.2301. Coverage for freestanding birth center services.
 
The National Center for Homeopathy calls for representaion on the Advisory Group as a relevant stakeholder in Integrated Healthcare. Homeopathy is the second largest system of medicine in the world. Homeopathy represents an evidence-based system of medicine in effect for over 200 years. Homeopathy has a body of research reflecting efficacy, safety, cost effectiveness and patient satisfaction.

The intent of the law, PPACA, is to include diversity in the health professions. Diversity can only be included in the whole vision when it is adequately represented.


The National Center for Homeopathy recommends inclusion on the Advisory Group of (1) member from each category of the national healthcare workforce as provided, that is, (1) licensed CAM provider, i.e., an MD homeopath who holds the national certification CCH, a DC who holds the CCH credential or other licensed CAM provider and (2) an integrative healthcare practitioner who holds the national certification CCH.


The National Center for Homeopathy will be happy to provide a list of qualified persons to consider for appointment to the Advisory Group. You may contact me directly.



Image7.  Charles Maclean: Comments from a patient advocate, integrative health activist & consultant

Charles MacLean, PhD is a healthcare and philanthropy consultant and an integrative health activist who presently serves on a patient advisory council for the Institute for Health Improvement. Portland, Oregon-based MacLean has also worked closely with the policy initiatives of the Gladys McGarey Foundation. Maclean shared this submission:
Appoint the required advisory task force NOW before any strategies or regulations are put in place.  Assure that there are savvy, open minded, collaborative representatives from Patient and Family Advocates and the major recognized and evolving alternative-integrated care professions. Fund the travel expenses of advisory panel members especially Patient Advocates.
Review and adopt the recommendations of the Samueli Institute. Incorporate the recommendations of the two white papers from the Gladys McGarey Medical Foundation.

Change language in the provisions/recommendations for integrated care options from"'may" to "shall."

   
 "Allocate funding to evaluate the financial
and health care outcomes of replicable
'peer to peer' health coaching models."

   
Do a cost-benefit analysis for providing every American with a $500 per year fund with a modest co-pay, which they control for integrative care from a list of pre-approved professions and pre-approved evidence based interventions. Track results using paired condition studies of 'traditional' interventions compared to 'integrative care' outcomes and costs.

Include funding to develop and deliver Patient and Family Advocate training, mentoring, coaching. Include funding to collect and widely disseminate the best practices and "stories'' of Patient and Family Advocates.

Allocate funding to evaluate the financial and health care outcomes of replicable "peer to peer" health coaching models. See the application of the Jonas Salk epidemic of health model, now being proven out by Heather Wood Ion,

Since only about 20%-25% of citizen health is attributable to the sickness care system of hospitals, care providers, technologies and pharmaceuticals, shift funds to early education and reinforcement of healthy behaviors and lifestyles and research what works and provide evidence based incentives for encouraging those behaviors and practices.


Image
Karah Pino, LAc
8.  Integrator publisher-editor John Weeks: Focus on health creating integrative practices


At some point this fall my urging that the integrative practice community respond to this opportunity finally reached my own ears. I began to think about my response, and finally submitted the following. I captured much of the same in my recent column
Positive Side-Effects: Evidence of Prevention & Health Promotion via Integrative Clinical Practices from Ornish, Cherkin-Sherman, Seely-Herman & Gaby.
What are your suggestions on the Draft Vision, Goals, Strategic Directions, or Recommendations?

My understanding is that the "integrative health care" language that is prominent in the "purposes and duties" of the Council was significantly a result of efforts to underscore the primary-prevention focus of many whole-person oriented practitioners and disciplines. These include "integrative medicine, holistic nursing, naturopoathic medicine, whole-person chiropractic, massage tehrapy, acupuncture and Oriental medicine, yoga therapists, and others. All totaled, there are over 350,000 licensed practitioners in this group. These proponents and practitioners of "integrative health care" have not typically been included in the nation's dialogue. I believe that Senators Harkin and Mikulski had inclusion in mind when they inserted this language at the request of the Samueli Institute, the Integrated Healthcare Policy Consortium, and others. (This language is also in the suggested members of the Council's Advisory Group.) While there is much that is good and even exceptional in this strategy, it does not embrace the importance of profoundly shifting clinical practice toward prevention and health promotion principles and away from the present reactive orientation of most clinical services.

   
 "While there is much that is good and
even exceptional in this strategy, it does
not embrace the importance of profoundly
shifting clinical practice toward prevention
and health promotion principles and away
from the present reactive orientation
of most clinical services."

   
A characteristic of clinical orientations that focus on working with causes (tolle causam), on bringing a person to health and not merely being reactive have in common that they routinely create "positive side effects." The reason is simple: when a clinician one works with therapeutic nutrition, stress, counseling, mind-body therapies and exercise for condition X (say, CV risk), the benefits are not limited to that condition. They are likely to positively influence any other health issue that the person has, given the importance of these factors in a huge array of conditions.
 
What evidence-based actions should the federal government take to address the Draft Recommendations?

The government needs to include in delivery settings and benefits plans licensed "integrative practitioners" and in research plans more examination of whether or not a given approach to care has health promoting and primary prevention benefits.

   
   
"A characteristic of clinical orientations
that focus on working with causes,
 on bringing a person to health and
not merely being reactive is that they
routinely create "positive side effects."


The logic is this: A characteristic of clinical orientations that focus on working with causes (tolle causam), on bringing a person to health and not merely being reactive is that they routinely create "positive side effects." The reason is simple: when a clinician one works with therapeutic nutrition, stress, counseling, mind-body therapies and exercise for condition X (say, CV risk), the benefits are not limited to that condition. They are likely to positively influence any other health issue that the person has, given the importance of these factors in a huge array of conditions. Here are just 3 examples:

1. See Dan Cherkin and Karen Sherman from Group Health Research Institute. Their goal:  " ... to provide insight into the full range of meaningful outcomes experienced by patients who participate in clinical trials of complementary and alternative medicine (CAM) therapies." The results of the study, published as "Unanticipated benefits of CAM therapies for back pain: an exploration of patient experiences" are as follows: "Our analysis identified a range of positive outcomes that participants in CAM trials considered important but were not captured by standard quantitative outcome measures. Positive outcome themes included increased options and hope, increased ability to relax, positive changes in emotional states, increased body awareness, changes in thinking that increased the ability to cope with back pain, increased sense of well-being, improvement in physical conditions unrelated to back pain, increased energy, increased patient activation, and dramatic improvements in health or well-being. The first five of these themes were mentioned for all of the CAM treatments, while others tended to be more treatment specific. A small fraction of these effects were considered life transforming."  The conclusion: "Our findings suggest that standard measures used to assess the outcomes of CAM treatments fail to capture the full range of outcomes that are important to patients. In order to capture the full impact of CAM therapies, future trials should include a broader range of outcomes measures." See: http://www.ncbi.nlm.nih.gov/pubmed/20180688

2. See Seely & Herman in research on a multi-factorial, mind-body integrative medicine intervention for employees of Canada Post with elevated CV risk found not only reduced risk and $1025 per employee in projected average cost savings but also "secondary" clinical outcomes via MYMOP self-reports related to fatigue, sleep, weight, stress, allergic symptoms, hypertension, coffee consumption, muscoloskeletal problems, etc. See: http://theintegratorblog.com/index.php?option=com_content&task=view&id=682&Itemid=189

3. Dean Ornish and colleagues, whose whole person, multi-practioner, multi-modality lifestyle-oriented INTEGRATIVE programs for reversing CVD was accepted for coverage my Medicare in 2010 writes in the New York Times "The only side-effects to comprehensive lifestyle changes are good ones." See:http://www.nytimes.com/2010/04/03/opinion/l03drug.html?emc=tnt&tntemail1=y

These are merely 3 examples. We would have many more, particularly if our research orientation turned to examining such multiple positive outcomes from multi-factorial integrative practices.

What evidence-based actions should partners (national, state, Tribal, local, and Territorial governments, non-profit, and private) take to address the Draft Recommendations?

Again, focusing on the same topic of promoting a major shift toward a health focus in our clinical practices though the principles, providers and practices of "integrative health care," consider:

1) Include (and measure outcomes of) such practices in community clinics, Tribal clinics, etc.

2) Give providers flexibility in who and what is covered under Medicaid and Medicare if the focus in on health promoting clinical interventions.

3) Since much evidence has only been poorly gathered and has NOT been the subject of significant study, make funding for pilot projects available.

4) As suggested in the Cherkin paper, above, begin to routinely ask if the intervention has any positive secondary effects relative to patient-centered perceptions of QoL. Examine whether such positive "side-effects" (secondary impacts) on health promotion and primary prevention are the outcome of drug interventions. In inpatient care, start including and examining "complementary" treatments that can foster recovery/promote health, prevent recurrence, including mind-body strategies, massage acupuncture. Examine the Allina Hospitals & Clinics integrative health initiative.

What measures should be used to monitor progress on implementation of the National Prevention Strategy's Vision, Goals, and Recommendations?

To monitor progress in health promotion and primary prevention in our clinical services, we must significantly elevate and better fund approaches that focus on functional outcomes that are evidence of promoted health and prevented disease.

Additional Comments or Suggestions:

   
"Congress required creation of an Advisory
Group with members from the community,
including licensed integrative healthcare
practitioners, for a reason. Please hold up
the declaration of a health promotion and
prevention strategy until you bring in
such advisers."
 
   
Congress required creation of an advisory group with members from the community, including licensed integrative healthcare practitioners, for a reason. Please hold up the declaration of a health promotion and prevention strategy until you bring in such advisers. Bring in Wayne Jonas or Janet Kahn. Thgese individuals can connect your broadly to the integrative practice community. The strategy's cart is presently before the horse. Take some time. The draft strategy begins with the statement that we have "an unprecedented opportunity to shift the nation from a focus on sickness and disease to one based on wellness and prevention." Well, begin with an unprecedented inclusion of the "integrative health care" principles, ideas and practitioners that this present strategy excludes. Live up to your own declaration of willingness to go where we have not trodden, as a government, before - but where millions of consumers of health care who have chosen integrative practices have gone, on their own: to clinicians who are focused on working with them toward health creation. Otherwise, I fear that for all the fine verbiage, the new strategy will not leave the old paradigm of reductive, non-integrative, precedent.

9.  Karah Pino, LAc: Responses to teh framework for the strategy

Karah Pino, MAcOM, LAc is a Seattle-based acupuncturist and self-confessed "geek" who responded to the first Integrator Alert! on the Council's draft framework for the strategy. I neglected to include her comments in a previously published summary. Apologies, Karah!
What are your general suggestions on the development of the National Prevention and Health Promotion Strategy (National Prevention Strategy)?

To maximize the functional impact of a National Prevention Strategy I would suggest a patient-centered, family-centered, community-centered approach. We are often trained as providers and policy makers to give prescriptions and directives through generalized guidelines. The guidelines, though helpful as starting points, do not take into consideration the level of participation that the patient/family/community is willing and able to engage in. This leads to every provider's greatest frustration: non-compliance.

   
"To maximize the functional impact of a
National Prevention Strategy I would
suggest a patient-centered, family-centered,
community-centered approach.
"
 
   
When approaching a treatment plan in a patient/family/community-centered way, we allow each individual and group to direct their own care. The plan then begins at the point where they are willing and able to commit to participation in promoting their own health. With a functional commitment by the patient, the hardest part of the task is done.

In this way, a health strategy along each of the Strategic Directions can be crafted as a matrix of opportunities for improvement where the provider's job is to offer guidance and information to the patient in their decision making. Decision making can be facilitated through any number of means (Dynamic Governance, for instance) Then the Generalized Guidelines for reaching the goals targeted by the National Prevention and Health Promotion Council can be used by individuals, families and communities as a multi-track curriculum, responsive to their own needs and goals.

What are your thoughts on the following elements of the Draft Framework:


Draft Vision:
Working together to improve the health and quality of life for individuals, families, and communities by moving the nation from a focus on sickness and disease to one based on wellness and prevention.

Overriding the current sickness model of Healthcare and transforming Americans into a culture of Wellness is indeed revolutionary task! Part of the challenge for policy makers as well as health care providers is in coherently and cohesively fostering an understanding that a whole-person wellness orientation creates a lifestyle where prevention is a by-product.

   
   "Making healthy choices isn't difficult,
it's the change itself that is difficult."


Remembering that the Latin translation of the term Doctor is "teacher", the core of prevention and wellness is fundamentally in the ability to inform, guide and support individuals, families and communities in making healthy choices for themselves not by a directive from the government, but by a localized process where the answers arise from within each community, family and individual.

The success of support groups such as Alcoholics Anonymous and Weight Watchers is a functional manifestation of a supportive community of peers. Making healthy choices isn't difficult, it's the change itself that is difficult. Expanding and fostering these kinds of communities based on common goals, such as in classrooms, workplace environments and neighborhood alliances will create a venue by which the National Prevention and Health Promotion Council can best disseminate its policy suggestions and gather back data on the impact of localized implementation. Research has clearly shown the importance of early intervention, particularly in the Strategic Directions of Healthy Eating, Mental Health and Substance Misuse, therefore, the revolution must begin in early education including involving parents.

Goals: In order to achieve the vision for the National Prevention Strategy, efforts will be targeted toward the following goals. Each goal can be applicable to every member of the Council and to many public and private partners.
1) Create community environments that make the healthy choice the easy and affordable choice
2) Implement effective preventive practices


Regarding the creation of Community environments that make wellness easy, while beginning with good education/ information dissemination is the place to start, long term change will require guidance and support on many levels. Community support is required to affirm healthy Family choices and family support is required to help healthy choices by individuals. And I cannot stress enough the importance of the workplace and classroom as key communities. Working people spend nearly 1/3 of their lives in the workplace and children spend nearly 1/4 their lives at school.

Implementation strategies must address the issues of wellness on both a conceptual and functional level. Education and creation of a shared vision of a wellness orientation in society can only come to fruition if the functional changes are systemic and consistent.

Strategic Directions

The ten Strategic Directions are all important places to begin measurement and Data collection using Quality of Life scales that will become standard across the board. Many of the Directions have overlapping impact points. I would recommend starting with a top three such as: Healthy Eating, Active Lifestyle and Addressing Specific Populations' Needs to Eliminate Health Disparities. The rest of the Directions can be initially addressed by refining the focus of these main Directions.

What recommendations should be included in the National Prevention Strategy to advance the Draft Strategic Directions?

The Draft Strategic Directions are:

  • Active Lifestyles:
  • Address Specific Populations' Needs to Eliminate Health Disparities:
  • Counter Alcohol/Substance Misuse
  • Healthy Eating
  • Healthy Physical and Social Environment
  • High Impact, Quality Clinical Preventive Services
  • Injury‐Free Living
  • Mental and Emotional Wellbeing
  • Strong Public Health Infrastructure
  • Tobacco‐Free Living

With a functional support structure from individual to community, the council can recommend simple changes that can take place along a continuum to create comprehensive change. Making healthy choices isn't difficult, it's the change itself that is difficult.

A key factor to implementing change is accountability. When accountability is measured in a rewarding rather than punitive way, healthy choices become easier. It is also important to have the periodic perspective from someone outside the family/community to apply measurements. This avoids the family/community from devolving into an enabling cycle. In time, with good facilitation training, the family/community can become increasingly more self directed. If accountability is measured by other families/communities that take turns measuring each other along the strategic direction, the sharing of strategies can magnify the success of all groups involved. Creating a circle of communities rather than a linear hierarchy maximizes the opportunities for evolution. (see the double linking structure of Dynamic Governance)

Do you have suggestions for how the National Prevention Council can work with state, local, tribal governments, non-profit, or private partners to promote prevention and wellness?

Individual Health accountability is something conventionally done in Primary Care. With a Primary Care shortage already congesting the public health system, it is vital to expand the range of people who can track individual and family Quality of Life measures.

   
"With a Primary Care shortage already
congesting the public health system,
 it is vital to expand the range of people
who can track individual and family
Quality of Life measures."

 
I would propose this include: Social Workers, Clergy, Human Resource Departments, Existing Community Organizations, Complementary Care Providers. School Counselors Etc. All these people have a great advantage over primary care in that they see people more frequently and have more time to spend with each individual. Having multiple options of who to talk with also allows individuals to choose whom they prefer to relate to as not everyone trusts their doctor or wants their human resources department to know about their health.

Being healthy isn't only measurable by one scale. If data collection is done regularly and with standardized outcome measures with a great deal of flexibility, a dynamic array of implementation strategies can evolve that is patient, family and community-centered. A flexible and dynamic system has the advantage of an accelerated evolution.

What prior federal prevention and health promotion efforts could serve as a model for the National Prevention Council?

For some reason, Smokey the Bear comes to mind. Growing up in the southern Rockies, Smokey the Bear was a memorable personification that I was able to relate to.

In the way that the changes of the 4 basic food groups were restructured into a food pyramid, an additional refinement of best choices can be created as guidelines for school and workplace cafeterias. Simple measures such as reducing unhealthy serving size and increasing healthy serving size with enough healthy options to appeal to a number of palates is an example.

The same can be applied to Active Lifestyles, Substance Misuse and Tobacco Free Living: Not everyone likes to run, some people enjoy dancing or weight-lifting more. Quitting an addiction requires a re-patterning into healthier responses to stress. Making multiple options available to be chosen by the individual/family or community with implementation guidance and a mechanism for accountability creates a feedback loop that supports healthy behaviors. Being healthy isn't only measurable by one scale.

Additional Comments:


I'm a fan of Dynamic governance as a model of self-directed decision making. It is a well developed facilitation technique that can be taught to families and communities to improve communication and evolutionary decision making.

As an Acupuncturist and Meditation teacher, I am passionate about the inclusion of these well developed models of Prevention and Wellness orientated techniques. Many CAM therapies exist in America only because people are inspired to utilize them. It would benefit the council to explore why it is that people are so drawn to seek out these modalities.

____________________

Overall Comment
: Here are the chief lines of continuity I pull out of this:

  • Don't publish until you have input from the Advisory Group. Appoint it!
  • Changes the title. National prevention Strategy will put people to sleep. Got a problem with engagement? This title guarantees the public will stay disengaged.
  • Present definitions and approaches are too limited for a transformative outcome.
  • Explore new types of practices and practitioners.
  • Use emerging community and self-care resources.
  • Engage integrative practice research that has health and wellness outcomes.
  • We need more research before we can declare a transformative national strategy - so proceed with that full in mind.

Practice wellness and mindfulness in this strategy-setting, Dr. Benjamin. Slow down. Consider the magnitude of the task of shifting the nation's course from one that is focused on disease to one that is based on health and wellness. These aren't merely words. Take this seriously. Take time.

In short and in all seriousness,
to use Dr. Seuss' parlance, we need to go On Beyond Zebra if we are to get this right. Or to quote from a similar tract from the same author:
"If I ran the zoo, said young Gerald McGrew
I'd make a few changes, that's just what I'd do ...
"
Let's see if the hasty authors of the draft Strategy soak up any of this commentary in their final draft. Right now the general sense from these members of the integrative practice community seems to be that it needs to go back to the drawing board if it wants to reach that to which it aspires.

Send your comments to
for inclusion in a future Integrator.




Last Updated ( Monday, 31 January 2011 )
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